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Original Question

Mr. González is a 70-year-old male who is a retired bus driver and was admitted after suffering from an ischemic, thrombotic stroke on November 26, 2020. He has been in the rehabilitation hospital for 6 weeks and now is now being prepared for discharge to his home with his wife. You are the discharge nurse completing the assessment. Mr. González is a DNR status and has no known allergies. He is a Catholic by religion. Mr. González, has a past medical history of type 2 diabetes. On admission he was also diagnosed with hypertension, hypercholesterolemia and constipation. He has no past surgical history. Mr. Gonzalez has started the following medications since admission: Metformin 500mg PO BID, Plavix 75mg, PO daily; Bisoprolol 5mg, PO daily, Atorvastatin 10mg, PO daily and Senokot 2 tabs, PO daily. His latest labs include a fasting BS of 8.4 taken this morning. His vital signs are as follows; T-36.8 degrees Celsius; Pulse (radial)-86 bpm; RR-17 breaths/min; BP is 148/96 mmHg; O2 sat-93% on room air; he denies any pain and reports no issues with sleeping. Mr. Gonzalez has mild dysphasia but is able to communicate well in English and Spanish, though takes a while to process words and respond appropriately. He has hemiparesis of his right side but can walk short distances with a walker, though is sometimes a little unsteady on his feet. His Hendrick II Fall Risk is currently 4. He requires some assistance to complete his ADLs such as bathing, dressing, toileting, and meal set up. Mr. González’ is continent of urine and feces. His appetite has decreased since his stroke, and he has lost 8 pounds in the past 6 weeks, now weighing 185 pounds. He is still only able to eat a minced diabetic diet with honey thickened fluids as otherwise he chokes. Mr. González’s abdomen is soft and slightly distended with hypoactive bowel sounds present in all four quadrants. He usually has a BM evert 2-3 days and it is hard and dry despite the laxative he is taking. Mr. and Mrs. González are both 70 years old and of Hispanic origin. They speak Spanish at home, though they are comfortable speaking English. On discharge, Mrs. González will be his primary caregiver and although they have no children they have a very involved extended family. Since he has new medications, he will need his blood pressure and blood glucose monitored frequently, requires assistance with his ADL’s, meal prep and set up, and has some safety concerns due to his hemiplegia. The nurse has been conducting a number of teaching sessions with Mr. González and his wife prior to discharge. These have also included fall prevention and stroke prevention. According to Mrs. González, the extended family believes in treating those who are “ill” with special foods and spices. The nurse conducts a more detailed assessment of home remedies with Mr. and Mrs. González and discusses the potential for harm from drug interactions. The nurse was informed that in the past week stressors have been interfering with the teaching sessions. Mr. González’s mood has become increasingly anxious, and he becomes easily frustrated. Mrs. González also seems anxious and concerned. She asks to speak to the nurse privately and confides that she “does not feel confident” about what she has learned and she is “worried” about being able to assist her husband with his care. She is also frightened that he might have another stroke. The nurse reassures her that a home care nurse will be visiting for the first few weeks to follow up on Mr. González’s care. She tells Mrs. González that she will call the home care nurse and provide an update of Mr. González’s status and inform the home care nurse of Mrs. González’s concerns. Data Collection Data Clustering Prioritizing 1. Patient information and assessment data collection Review and collect the assessment data about your client in the case study. Name DOB/Age Date of Admission Date of Assessment Gender Identification Allergies Code Status Religion Admitting Diagnosis ­­­ Past Medical History (diagnosis and date of diagnosis if possible) Past Surgical History (diagnosis and date of diagnosis if possible) Medication Dose Route Frequency Reason YOUR patient is taking Vital Signs Temp HR (Pulse) BP RR O2Sat on R/A or amount of O2 Pain O = Onset P = Provocation/Palliation Q = Quantity/ Quality R = Region/Radiation S = Associated S&S T = Timing U = Understanding Last Pain Medication? Effect? Sleep & Rest Sleeping patterns (#h/d) Naps Use of sedation Feeling rested? Mobility Gait, balance Independently ambulatory W/C, Walker, Cane, Crutches Bed ridden Level of assistance required for movement (transferring, getting out of bed, walking) Neurological Level of Consciousness Orientation Mental Status GCS Number Communication Language Vision Hearing Cardiovascular Radial pulse – rate, rhythm, strength Apical pulse – rate, rhythm Heart valve characteristics Capillary Refill Peripheral Pulses X 4 BP Edema – description, extent, pitting or non-pitting Respiratory Respirations – Rate, Rhythm, Depth, Characteristics, Adventitious Sounds Cough (productive or non-productive) Secretions Suction Requirement O2 Saturation Oxygen Therapy Gastrointestinal Abdomen shape, Scars, Lesions Bowel sounds Abdominal palpation BM – last one, usual bowel patterns Bristol bowel movement description Continent/incontinent stool Height Weight BMI Diet Amount consumed Ability to eat, physically and psychologically Genitourinary Continent/incontinent urine Catheter Condition of Perineal Skin Discharge/odor Urine Assessment – characteristics, amount Musculoskeletal Upper body strength Lower body strength ROM Contractures/abnormalities Integumentary Colour Temperature Skin Texture Skin Turgor Lesions/wounds Scars Braden scale Ability to manage hygiene need Psycho-social (SELFACNG) S – Self-Esteem: pertaining to hygiene, grooming, eye contact, statements about oneself and any other characteristics that provide information about the patient’s self-esteem, Sense of self, in relation to the world, Sense of meaning and purpose, Value base, Evidence of Emotional Distress, Grief Issues E – Energy Level: Patient’s with psychological problems often have an alteration in level of activity. L – Lifestyle: Living arrangements, significant relationships, occupation, hobbies or lack of interest in leisure activities, education, and any other data that provides information about the patient’s personal situation. F – Family System: contact and support from family members or significant others, family stressors, crisis events, and coping skills. A – Affect: mood or emotional feelings. It may be described as happy, euphoric, flat, inappropriate, and other descriptive terms. C – Culture: refers to all cultural, racial, or anthropological variables that influence one’s lifestyle and mental health, may refer to issues of homelessness, religious and spiritual preferences, if any. Discuss any related food needs and other areas of impact culture will have on their health status. N – Needs: As expressed by the patient G – Goals: As expressed by the patient Lab Values & Diagnostic Tests Date of lab work Normal value Tubes Insitu IV / central line / PICC, Foley catheter, NG, PEG/G-tube, drains IV site, solution, rate Safety Falls Risk Safety Measures – call bells, bed rails, seatbelts, lap tray Psychological Security Discharge Plans/Care Discharge teaching Care on discharge 2. Clustering of Data: Cluster assessment data from above into the boxes below. From the list of assessment data, you collected, group similar data together. These groupings will help you to identify the health problems for your client. Put a ‘name’ to the problem in the blue box at the top of each cluster, e.g respiratory, .. 3. Identifying 1 priority problem area (rank 1-4): go back to the cluster sets above and rank them from most urgent (#1) to least urgent (#4). (This will be dependent on the amount of abnormal data in each box and the severity of the abnormal data, e.g., breathing will be more of a priority than constipation).

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